Pediatric/Adolescent Sports Injuries: Pearls and Pitfalls

Richard W. Kruse DO MBAClinical Professor Orthopaedic Surgery

Sidney Kimmel Medical CollegeThomas Jefferson University

Pediatric Orthopaedic SurgeonNemours AI DuPont Hospital for Children

Disclosures

• Dr. Richard Kruse has no financial conflicts of interest to disclose relevant to this activity.

Learning Objectives

• Review the approach to sports related knee pain and current treatment recommendations

• Discuss the physical examination in the differential diagnosis of ankle pain

• Identify common hand and finger injuries, and how to treat them

Pearls:

• You can’t make a good decision on bad x-rays• In doubt? Every patient should be followed to

“declaration” or “resolution”

NOTHING CURES CONFIDENCE LIKE FOLLOW UP: don’t jump to conclusions!

Ankle Sprains-Most Common Problem to Me

• Three Main Types• Lateral Ankle Sprain- Most Common

• Plantarflexion/inversion• ATFL/CFL

• Medial Ankle Sprain• Eversion/External rotation• Often collision/contact injury• Deltoid Ligament

• “High” Ankle Sprain• External rotation/dorsiflexion• AITFL

Take it seriously

• Most prevalent musculoskeletal injury in physically active populations as well as a common condition in the general population and has numerous sequelae that contribute to a substantial healthcare burden.

• High recurrence rate

• Direct and indirect financial and societal costs for treating lateral ankle sprains and their sequelae are high.

Lateral Ankle Sprains

• History- inversion• Anteolateral Ankle Pain• DIFFERENTIAL DX• Ability to bear weight immediately?• Prior history of sprain/instability?• Fatigue? Eg tournaments/multiple sports

• Physical- anterolateral pain/swelling• IMPORTANT: Site of tenderness• Skeletally immature SHI fx• Range of motion• Drawer test/inversion/external rotation

Pearl-Ankle Anatomy

• all ligamentous structures attach distal to the physis- to the epiphysis

• ligaments are stronger than physis

• physeal injury more common

Medial Ankle Sprains/High ankle sprains

• Be wary of Fracture• Syndesmosis injury-mechanism• Significant ligamentous injury• EXAM: Location of:

• Tenderness• Swelling• Kleiger’s test• Hopkins “squeeze test”

Ankle Sprain Basic Physical Exam

• Pain may Prohibit• My Comment on testing

• Localize pain and swelling• Stabilize foot

• ANTERIOR or atypical tenderness caution

• Pain on external rotation• Syndesmosis

X-rays? –WEIGHT BEARING/simulated weight bearing if possible

Salter I Distal Fibula –typical “goose egg” swelling over distal fibula with tenderness over distal fibular physis

Ankle Sprains- Treatment

• “PRICE”• Immobilization

• Cast/brace/splint• Facilitates mobility

• Early Rehab critical-re-injury common-21 articles 2009• Am J Sports Med. 2009 • Arch Phys Med Rehabil. 2009

• Protect (brace) on return to sport-my anecdotal guidelines-Balance deficits seen in chronic injury (MSSE Aug 2009

• 1st-2-4 weeks after return to sport• 2nd-2-4 months• 3rd 6 months min

• Brace-(up to 1 yr recommended by some after first sprain)

Ankle Sprain Treatment-most common reason for repeat sprain is not healing the FIRST ONE

• Manual Therapy• Some support• Also in chronic

• Neuromuscular Training• Reduce overall injury rate in kids!

• Orthobiologics (PRP)• Not there yet

• Return to Play• Minimal Pain/swelling• Motion• Sport specific activity

Neuromuscular Training

• Study on female basketball/volleyball

• Reduced injury rate• KNEE – particularly benefits

Ankle Instability-

• 40-75% of individuals experiencing an ankle sprain will have ongoing symptoms of pain or instability-Marshall et. al. MSSE Aug 2009.

• Ankle dysfunction is associated with proximal physiologic/balance compensations and adaptations -Nadler 1998

Core and Rehab-?Data

Trunk Balance and ankle instability-Marshall et al. MSSE Aug 2009

Differential Diagnosis and Sprains that don’t heal

• Instability versus Pain• Note previous discussion• Overall evaluation

• Differential Diagnosis:

Ankle Sprain that didn’t Heal-Anterolateral Talar OsteochondritisDissecans (OCD)

Fracture of the Lateral Process of the TalusLELAND G. HAWKINS M.D. University of Iowa 1965

Pain about the lateral side of the ankle

The initial diagnosis was frequently missed.

Ankle Sprain that doesn’t heal-continued

• Tarsal coalition- the stiff hindfoot/Rigid flatfoot• Cavus foot –especially unilateral-neurologic cause

• “BEWARE THE CAVUS FOOT”• NEUROMUSCULAR/SPINE

Peroneal Tendon Subluxation

Tenderness posterior to the lateral malleolus;

Subluxation of the peroneal tendons may be provoked by having the patient dorsiflex the foot from a position of dorsiflexion and eversion;

Consider in cases of recurrent sprains

Cast in inversion/plantar

eorthopod.com

Posterior Process talus

• Shepherd’s fracture (1882)

Os Subfibulare fracture

Sever’s Disease

• Apophyseal focal heel pain in the skeletally immature athlete

• Etiology overuse v smetaphyseal injury (Ogden 2004)• Activity modification, ice, stretch, heel cups• CAST• Probably not an inflammatory condityion but repetitive

microtrauma to an actively remodeling bone based on mri studies

• Xray not initially needed if no acute trauma• Pain resolves with Rx

• Mri not initially needed

Calcaneus-Understand the Apophysis-Normal undulations

Sever’s may be a “fracture” of metaphyseal bon where the apophysisattaches- Ogden JPO 2004

Immobilization in a short leg cast for 4-6 weeks may provide the quickest long term relief-Frush/LindenfeldSports Health 2009

Fifth metatarsal Base Fracture

• Inversion injury similar to sprain

• Focal tenderness MT5 base• Differentiate from apophysis

• Apophysis parallel to MT

• Three zones of injury• “Do not walk across this line”

• 2-4 weeks protection for apophyseal

• Any other fracture NWB in cast---?surgery

Knee: Pain and selected Problems

Knee Anatomy-2 tendons, 2 menisci, 4 ligaments

Patellofemoral Pain

• Pain behind or around patella• Particularly during loading

• Cause multifactorial • (still mostly unknown)• Malalignment• Muscle weakness • Core

• ? Altered Central Pain Processing• Chronicity

• May not be self-limiting• >50% after 5-20 years!!• Relation to Osteoarthritis unclear

Patellofemoral Pain Risk Factors

• POOLED evidence clearly implicates imbalance:

• Quads• Hip Abduction

Strength

Nothing is ever easy

Is Patellofemoral Pain Preventable?

• ”Braces”may help in :• Young adults –training increased• Military recruits

• Foot orthoses no proof• Strengthenig/stretching

• Studies poor to date

• Neuromuscular control• ?

Consensus Statement

• 51 experts• 10 countries

Evidenced Based Management of Patellofemoral Pain

• Consensus of 2017 Patellofemoral Pain Research Retreat• Six recommendations

• 1. Exercise recommended to reduce pain in short, medium, and long term• 2. Hip and Knee Exercises• 3. Combined interventions exercise and one of the following:

• Foot orthoses in the short term• Patellar taping• Manual therapy

• 4. Foot orthoses• 5. Patellofemoral, knee, lumbar mobilization not in isolation• 6. Electrophysical Agents not recommended

Education

• Fig. 4. Manage My Patellofemoral Pain education leaflet (Printable version downloadable here. http://bmjopensem.bmj.com/ content/bmjosem/2/1/e000086/F1.large.jpg).

Osgood Schlatter Syndrome

Pain directly over tibial tubercle DIRECTLY!

Traction by the patellar tendon on the apophysis

Age 8-12 girls a little older in boys Treatment:

Activity modification Ice NSAIDS Quad Stretching Immobilize for severe pain

Osgood Schlatter-treatment may take time

• NO prospective, randomized, controlled trials on treatment• Krause (JPO 1990) low incidence of later anterior knee pain• Ross and Villard (J Strength Cond Res 2003) Some residual

limitations in Air Force Academy Cadets• Most investigators –resolution of pain in 90% but it may take 9-24m • Get the pain down to a minor “annoyance”• WARN FAMILY: MAY TAKE TIME AND WAX/WANE

Pitfall: Hip or Knee?

• Pitfall:• Knee pain may be hip• Failure to Appreciate

severity of pain/gait• Failure to Obtain an

appropriate x-ray

• Pearls:• Knee hurts-check hip• Early referral• Expeditious X-ray• AP and Frog pelvis (both

hips)• Lateral x-ray!

SCFE

My take- The Knee/Ankle is often the ”victim” and not the “culprit”

• Check overall fitness level• Exercise is Medicine

• But NOT TOO MUCH!?

• Check hip/core/balance• Attention fatiguing of hip abduction and weakness of external rotators• Hip Drop on single leg stance• Fatigue/balance

• Xray ?• Physical therapy• Bracing Options

“Try before you buy”• ? Foot orthoses off shelf

Some Acute Knee Injury Issues: Common

Pitfalls: Patellar Dislocations

• Almost always lateral-tear of retinaculum/medial patellofemoral ligament

• Younger age at initial dislocation, increased risk of recurrent dislocation

• Often reduce spontaneously with knee extension and present with hemarthrosis

• Pearl: Get xrays-important to check for associated fracture

• Immobilize for 4 weeks (subluxations can move earlier)

Patellar DislocationNote Medial Avulsion off Patella and Laxity in Medial Retinaculum-tear of medial patellofemoral ligament-

Growth plate injuries may be unstable and nondisplaced

Pearl:

Refer injuries that swell shortly after injury Remember the weak growth plate

Pitfall:

Pain over a Bone not appreciated as fracture

Pitfall:Acute Hemarthrosis in Children-without Obvious Fracture x-ray/?mri

• Pearls-: • Anterior Cruciate Tear• Meniscal tear• Xrays yes• Patellar dislocation +/- osteochondral fracture• Strongly consider mri in primary traumatic patellar

dislocation with large effusion and normal x-ray• need to state concern for mri approval

Patella Fractures-Pitfall: Patella Sleeve Fracture

• Remember small fleck principle

• avulsion mechanism• Restore articular

surface and knee extensor mechanism

Pitfalls-Ordering X-rays

• Pearls:• Include joint above and below• Weight bearing joints taken in weight bearing position

whenever possible-foot!!!!• Discipline Yourself: Where’s the tumor?

• Distal femur may be missed on knee x-ray!!!!!!• Be careful on accepting x-ray report• Every patient should be followed up !!!!!• Persistent pain is a worry

Pitfall: “There is repetition everywhere, and nothing is found only once in the world.”-Johann Wolfgang von Goethe

• Pearls: Remember x-ray ordering. Could you be missing a proximal tibial tumor not seen on an x-ray of the knee?

• Trauma is often the gateway to tumor diagnosis and bone is a window to watch metabolic bone disease

• Follow patients with persistent pain• Leukemia may present as bone pain• ? Vitamin D/Diet

Ewing’s Sarcoma

Initial Care of Fractures and Referral

• Fingers within three days• Displaced epiphyseal fractures

within 5 days• Reduction of epiphyseal fractures

risky after 5-7 days• Risk of further growth plate

injury

Pain is telling you something

• Elevation, elevation, elevation, elevation, elevation, elevation, elevation, elevation

Principles of Splinting

• Please splint, it’s humane• Joint above and joint below• Beware foam and aluminum-

sores• Beware heel pain in splint• There are no hypochondriacs

in casts or splints

Fingertip Injuries –distal phalanx and distal interphalangeal joint• Avulsions• Mallet fracture-can’t straighten distal

phalanx• Jersey finger- flexor tendon avulsion –

can’t bend distal phalanx• fractures

Distal Phalanx-most common Childhood Injury/fracture

• Extensor epiphyseal• Flexor metaphyseal• Three layers of nail• Subunqual hematoma

• Drain vs nail removal

• Hand Injuries-Mallet Finger

• Distal Interphalangeal Joint- (DIPJ)• Salter-Harris III fracture or extensor tendon avulsion• Unable to actively extend DIPJ• Dorsal Splint in extension full time 6-8 weeks

Distal Phalanx- “Seymour Fracture

• Open Fracture disrupt matrix and nailbed

• Reduce +/- pin, repair nail bed• 6-0,7-0 ABSORBABLE suture

Hand Injuries- “Jammed Finger” Swollen PIP joint

• Proximal Interphalangeal Joint (PIPJ) hyperextension• Consider early referral for anything more than minor

sprain• With or without subluxation or dislocation

• Treatment:• Reduction by linear traction• Check for fracture • Brief period of immobilization (splint then buddy tape)• Followed by edema control (elastic bandage)• Return to sports 1-2 weeks-longer if severe fracture• Pain/swelling may last months

Condylar neck Fractures

Phalangeal Base Fracture

• Closed reduction• Check rotation• Splint/cast 2-4weeks• Know splinting “safe

positon:• padding

• Does finger Stick out?

Fifth Metacarpal Fracture-“Boxers Fracture”

• Punching inappropriately• Dropped knuckle• Angulation?

• 45-50 deg?

• Ulnar Gutter Splint/cast• Heal fast 2-3 weeks• Extensor Lag?

Pearls-Executive Summary

• Splint fractures or suspected fractures• Beware the compressive wrap• Pad, pad, pad splint• Foam on the inside of metal splints macerates skin quickly• When/How do you get x-rays interpreted?

• Beware the jammed finger• Consider Referral anything more than a minor sprain• Fingers heal and stiffen FAST refer soon 3-5 days• AP/Lat/Oblique xray centered on joint of interest

• Hip/Groin Pain-Beware the unilateral hip xray-• If a knee is injured immediately swells big time-

refer

Executive Summary-Referral Pearls/Pitfalls

• ANY crooked injured extremity significantly swollen joint or extremity- if you send them to the ER or for urgent evaluation keep them NPO and please approve us for x-rays if possible

• Suspected SCFE: NPO and discuss with ortho• Creates a weird situation with family when you get x-ray

report days after their visit to you, refer later and we tell them they need surgery NOW!

• If not absolutely sure don’t tell them specifics about what ortho will do. It creates confusion if there is ANY deviation in plan.

• Lack of “referral” or approval for care delays care and makes us all look bad-eg sending directly from x-ray to ortho

EXPERIENCE IS SOMETHING YOU LEARN JUST AFTER

YOU NEEDED TO KNOW IT

One brick too many